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 Importance And Implementation Of Nursing
Documentation: Review Study

Osama A Alkouri K ​ ing Abdulla University Hospital, Catheterization department, Irbid,

Jordan ​Ahed J AlKhatib ​Department Of Legal Medicine, Toxicology of Forensic Science
and Toxicology, School of Medicine, Jordan University of Science and Technology (JUST),
Irbid , Jordan ​Mariam Kawafhah ​Irbid National University, Jordan

doi: 10.19044/esj.2016.v12n3p101 URL:http://dx.doi.org/10.19044/esj.2016.v12n3p101

Abstract ​This study was conducted to review the literature about nursing documentation.
​ We
presented the importance and implementation of nursing documentation. The importance of this
topic has been realized here, in Jordan, and the Ministry of Health has recently started
application of electronic documentation systems. Nursing documentation can be either paper
based or electronic based documentation. Paper based documentation has been described not
meet the required standards. We argued the standards of nursing documentation that should be
met including completeness, clearing, and concision.

Keywords: ​Nursing documentation, paper based documentation, electronic documentation

Introduction
Nursing documentation is considered as an important indicator to develop nursing care.
According to patient safety law, nurses have to document nursing interventions (Öhlén, 2015). In
Europe, it has been pointed to the attempts to standardize nursing records (Thoroddsen et al.,
2009).
On the global level, the nature of nursing career involves that nurses carry out similar
duties including the documentation of patients’ care, assessments and finding and outcome of
care (Hearthfield, 1996). In their study, Moody and Snyder (1995) showed that documentation
took about 15- 20% of the nurses’ time.
European Scientific Journal January 2016 edition vol.12, No.3 ISSN: 1857 – 7881 (Print) e - ISSN 1857- 7431 ​According to Irving et

al (2006), nursing documentation can be viewed as the record of care planned and or care
provided to patients. Nursing documentation was described by the College of Registered Nurses
of British Columbia (CRNBC, 2007) as a generated information, written or electronic, that
describes the care or service rendered to individual client or group of client. In fact it is an
accurate account of what has occurred and when it occurred.
 Two studies, Bakken (2007) and Hansebo et al (1999), expressed their views regarding
nursing documentation to involve a description of nurses tasks, a method for problem solving
and decision making as well as a theoretical or philosophical model of thinking and describing
the care process.

The reasons for nursing documentation

It is thought that the importance of nursing documentation cannot be overemphasized.
Furthermore, nursing documentation is considered as a way of communication, and presents as
an indicator for quality of care (Ammenwerth et al., 2003). Nursing documentation is considered
a crucial phase in the nature of nursing as a career with the purpose of determining the factors
that help nursing process and others that form the bases of nursing decision-making
(Karkkaninen and Eriksson, 2003).
It is worth to mention that the perception of nurses towards documentation implies
nursing documentation as a significant step in their daily practice as well as emphasizing patients
safety (Bjorvell et al., 2003). Nursing documentation offers various options to enable nurses
making choices regarding decision making for optimal care ( Jefferies et al., 2010).
According to Cheevakasemsook et al (2006), nursing documentation has the following
important aspects which include offering a legal evidence of the medical process and outcomes
of care; providing an instrument or tool to assess the quality, efficiency and effectiveness of
patient care; giving evidence for several issues such as research, financial and ethical quality-
assurance purposes; providing the database infrastructure supporting development of nursing
knowledge; and helping in creating benchmarks to develop nursing education and standards of
clinical practice. It has been argued that optimal use of nursing documentation is likely to
achieve if documentation is accurate (Ellingsen and Munkvold, 2007).

Principles of documentation
Appropriate nursing documentation has various principles including objectivity,
specificity, clearing and consistency, comprehensive, respecting confidentiality, and recording
errors (Chelagat et al., 2013).

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Quality of nursing documentation

Documentation is considered as a communication tool to exchange the information stored
in records between nurses and other caregivers (Urquhart et al. 2009). It is believed that the
quality of nursing documentation plays very important roles in encouraging structured, consistent
and effective communication between caregivers and facilitates continuity and individuality of
care and safety of patients (Bjo ̈ rvell et al. 2000, Voutilainen et al.2004).
Nursing documentation has been defined as the record of nursing care that is planned and
given to individual patients and clients by qualified nurses or by other caregivers under the
direction of a qualified nurse (Urquhart et al. 2009). Nursing documentation is an attempt to
present the issues that occurred in the nursing process and the information that leads to
decision-making including admission, nursing diagnoses, interventions, and the evaluation of
progress and outcome (Nilsson and Willman 2000, Karkkainen and Eriksson 2003).
Nursing documentation has other uses such as quality assurance, legal purposes, health
planning, allocation of resources and nursing development and research, and accordingly nursing
documentation has to have valid and reliable information and to be compatible with working
standards (Idvall and Ehrenberg 2002, Karkkainen and Eriksson 2003, Urquhart et al. 2009).
The history of nursing documentation has started since the early days of Nightingale
(Gogler et al. 2008). It is worth to mention that nursing documentation was improved with the
introduction of the nursing process into the clinical setting (Oroviogoicoechea et al. 2008). The
nursing process is regarded as a scientific approach in which critical thinking is used to solve
problems and this approach was introduced into nursing practice and education Yura and Walsh
in 1967 (Wang et al., 2011).
Nursing records are usually of low quality (Wan et al., 2011). Several studies showed that
nursing documentation records were insufficient regarding the nursing care provided to a patient
(Ehrenberg and Birgersson, 2003; Voutilainen et al., 2004; Irving et al., 2006; Mahler et al.,
2007; Oroviogoicoechea, Elliott, and Watson, 2008). It was also indicated that data was not
concisely and clearly presented (Whyte, 2005).
It has been recognized that the traditional paper based documentation does not cope with
modern health requirements, and this may due to the nature of manual documentation process in
which documentation is often repetitive and manipulation of data is not an easy process
(Cheevakasemsook et al., 2006; Yu et al., 2008). Other studies pointed to withdraw backs of
paper-based records in which documentation is illegible, lacking information about
individualized patient care, containing useless information and missing

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European Scientific Journal January 2016 edition vol.12, No.3 ISSN: 1857 – 7881 (Print) e - ISSN 1857- 7431 ​the signatures of care staff
(Ammenwerth et al., 2001; Whyte, 2005; Urquhart et al., 2009).
The use of information technology has witnessed wide use by health care organizations to
support care delivery because electronic documentation systems help in data capturing through
the use of structured date entry and formalized nursing language (Ehrenberg and Ehnfors, 2001).
Electronic documentation systems have the advantages in offering health professionals with
increased access to more complete, clear, accurate, legible and up-to- date patient information
(Helleso and Ruland, 2001; Oroviogoicoechea, Elliott, and Watson, 2008).

Conclusion
Nursing documentation is very crucial in health care settings and reflects various aspects
including the awareness level of nurses in their roles in providing health services in a good
quality. Nursing documentation have two main forms: paper based documentation and electronic
based documentation. Paper based documentation has certain drawbacks such as lacking the
comprehensiveness and clarity. Accordingly, a strong trend to shift paper based documentation
towards electronic documentation has been witnessed.

References: ​Agneta Öhlén (2015). ADVANCED HOME CARE NURSES' EVERYDAY

PRACTICE. PhD thesis, Karolinska Institute, Stockholm, Sweden. Ammenwerth E, Eichstadter
R, Haux R, Pohl U, Rebel S, Ziegler S. A (2001). Randomized Evaluation of a Computer-Based
Nursing Documentation System. Methods inf. med., 40: 61-68. Ammenwerth, E., Mansmann,
M., Iller, C., Eichstädter, R. (2003). Factors affecting and affected by user acceptance of
computer-based nursing documentation: results of a two-year study. Journal of the American
Medical Informatics Association, 10(1), 69-84. Bakken, S. (2007). Building standard-based
nursing information systems. Washington, DC: Pan American Health Organization. Bjo ̈ rvell
C., Thorell-Ekstrand I and Wredling R (2000). Development of an audit instrument for nursing
care plans in the patient record. Quality in Health Care 9, 6–13. Bjorvell, C., Thorell-Ekstrand, I.,
Wredling, R. (2003). Prerequisites and consequences of patient records as perceived by a group
of registered nurses. ​Journal Of Clinical Nursing, 12, 2​ 06-214. Cheevakasemsook A, Chapman
Y, Francis K, Davis C (2006). The study of nursing documentation complexities, Int J Nurs
Pract., 12:366 -374. CRNBC (2007). Nursing Documentation. Crnbc, 151, 1-24.

104
European Scientific Journal January 2016 edition vol.12, No.3 ISSN: 1857 – 7881 (Print) e - ISSN 1857- 7431

Dinah Chelagat, Tecla Sum, Millicent obel, Alex Chebor, Robert Kiptoo, Priscah
Bundotich-Mosol (2013). Documentation: Historical Perspectives, Purposes, Benefits and
Challenges as Faced by Nurses. International Journal of Humanities and Social Science, 3 (16):
236-240. Ehrenberg A, Birgersson C (2003). Nursing documentation of leg ulcers: adherence to
clinical guidelines in a Swedish primary health care district. Scand J Caring Sci., 17: 278-284.
Ehrenberg A, Ehnfors M (2001). The accuracy of patient records in Swedish nursing homes:
congruence of record content and nurses' and patients' descriptions. Scand J Caring Sci., 15:
303-310. Ellingsen, G., Munkvold, G. (2007). Infrastructural arrangements for integrated care:
implementing an electronic nursing plan in a psychogeriatic ward. International Journal of
Integrated Care, 7, 1-11. Gogler J., Hullin C., Monaghan V. Searle C (2008). The chaos in
primary nursing data: good information reduces risk. HIC 2008 Australia’s Health Informatics
Conference ISBN 978 0 9805520 0 3. Hansebo, G., Kihlgren, M., Ljunggren, G. (1999). Review
of nursing documentation in nursing home wards-changes after intervention for individualized
care. Journal of Advanced Nursing, 29, 1462-1473. Hearthfield M (1996). Nursing
documentation and nursing practice: a discourse analysis. Journal of Advanced Nursing, 24,
98–103. Helleso R, Ruland CM (2001). Developing a module for nursing documentation
integrated in the electronic patient record. J Clin Nurs, 10: 799-805. Idvall E. and Ehrenberg A.
(2002). Nursing documentation of postoperative pain management. Journal of Clinical Nursing
11, 734–742. Irving K, Treacy M, Scott A, Hyde A, Butler M, MacNeela P (2006). Discursive
practices in the documentation of patient assessments. J Adv Nurs, 53: 151-159. Jefferies, D.,
Johnson, M., Griffiths, R. (2010). A meta-study of the essentials of quality nursing
documentation. International Journal of Nursing Practice, 16(2), 112-124. Karkkainen O. and
Eriksson K. (2003). Evaluation of patient records as part of developing a nursing care
classification. Journal of Clinical Nursing 12, 198–205. Mahler C, Ammenwerth E, Wagner A,
Tautz A, Happek T, Hoppe B, Eichstadter R (2007). Effects of a computer-based nursing
documentation system on the quality of nursing documentation. J Med Syst, 31: 274-282.
Moody, L., Snyder, P. (1995). Hospital provider satisfaction with a new documentation system.
Nursing Economics, 13, 24-31. Nilsson U.B. and Willman A (2000). Evaluation of nursing
documentation. Scandinavian Journal of Caring Sciences 14(3), 199–206.

105
Ning Wan, Ping Yu, David
European Scientific Journal January 2016 edition vol.12, No.3 ISSN: 1857 – 7881 (Print) e - ISSN 1857- 7431 ​

Hailey, Deborah Oxlade (2011). Developing Measurements of Quality of Electronic versus

Paper-based Nursing Documentation in Australian Aged Care Homes. electronic Journal of
Health Informatics, 6(1): 1-6. Ning Wang, David Hailey, Ping Yu (2011). Quality of nursing
documentation and approaches to its evaluation: a mixed-method systematic review. Journal of
Advanced Nursing 00(0), 000–000. doi: 10.1111/j.1365- 2648.2011.05634.x Oroviogoicoechea
C, Elliott B, Watson S (2008). Review: evaluating information systems in nursing. J Clin Nurs,
17: 567-575. Thoroddsen A, Saranto K, Ehrenberg A, Sermeus W. (2009) Models, Standards and
Structures of Nursing Documentation in European Countries. Study of health care technology
information;146:327-331. Urquhart C, Currell R, Grant MJ, Hardiker NR (2009). Nursing record
systems: effects on nursing practice and healthcare outcomes. Cochrane Database of Syst Revi.
Issue 1. Voutilainen P, Isola A, Muurinen S (2004). Nursing documentation in nursing homes –
state-of-the-art and implications for quality improvement. Sand J Caring Sci., 18: 72-81. Whyte
M (2005). Computerised versus handwritten records. Paediatric Nursing, 17:15-18. Yu P, Hailey
D, Li H (2008). Caregivers’ acceptance of electronic documentation in nursing homes, Journal of
Telemedicine and Telecare., 14: 261-65.

106